When Your Patient Can't Get Pregnant- And You Are

Now that I am again expecting, I am wondering how to approach potentially difficult clinical situations in my Internal Medicine practice. It’s too early right now for my pregnancy to be obvious, but I know that it will soon be very obvious to my patients who are struggling with infertility issues or pregnancy losses. Not only that, but I am struggling with my own emotions when I counsel patients through miscarriages or pregnancy complications.

Last pregnancy, when I walked into the exam room at 6 months to see my patient with a cough, it was painfully, massively obvious that I was pregnant. This patient is a lovely woman, about 42 years old. She and her husband had been trying to conceive for several years. She had tried Clomid, in utero insemination (IUI), and several cycles of in vitro fertilization (IVF). They had used up their infertility treatment insurance benefits and a large chunk of savings on the project. We had spoken of her issues before, and I had provided referrals for her to a new fertility center, to try again. But that day, she was only in for her cough.

When I was at 6 months, almost anyone who saw me commented on my pregnancy. Patients would almost invariably enthusiastically ask: A query as to how it was going, how I was feeling, did I know if it was a boy or a girl, etc. I welcomed this banter and enjoyed the opportunity to chat with patients, as most times the banter led to some memories from the patient on their own pregnancies, or expressions of hopes for future pregnancies, or descriptions of beloved nieces and nephews or grandchildren. In short, a pleasant time was generally had by all.

But this patient was clearly pained by my state, and the visit was strained to the max. As soon as I walked into the room, she seemed shocked, silenced, and took some time to get composed. It did not occur to me right away what the issue might be, so I asked her some questions about her illness. The visit progressed, I took care of her cough, but she never once commented or said anything about my state. She kept looking at me as if I had somehow betrayed her. She fairly fled the room at the end of the visit, clutching her prescriptions. I felt terrible.

Afterwards, I asked colleagues how I could have handled this better. It had seemed as if there was an elephant in the room- and at my size, there literally WAS an elephant in the room. They suggested that I acknowledge the elephant, say something like, “It’s possible that my state is upsetting to you right now, and it’s no problem at all for me to find another provider to care for you, if you like” type of thing. I think that with this pregnancy, I’ll be more sensitive to these situations, and likely offer something like that. I’m curious as to what other providers do, especially the OBs, who much encounter these situations far more often than I do.

Now, I am 9 weeks along. I’m exhausted, emotional, and a tad nauseated, but other than being various shades of green during exams, I don’t think anyone would know that I was pregnant. However, it comes up for me, on my end, with the emotions I have in caring for my patients who are having pregnancy issues. Two weeks ago, I counseled one patient through an early miscarriage. She had had a hard time getting pregnant, and the loss was such an overwhelming disappointment to her and her husband. I couldn’t help imagining what it would be like for me, for us, to go through the same thing; as a result, it was difficult for me to contain my own tears in front of them.

I have another wonderful young patient who is struggling with a complicated early pregnancy, right now. She has numerous health issues, and hers is a very much desired pregnancy that has been a long time in the trying. Our LMPs were close to the same date. She does not know that. My pregnancy has progressed pretty normally thus far; hers has been fraught with vaginal bleeding and erratic HCG levels; an early ultrasound showed a small gestational sac with no heartbeat, and she was counseled to hope for the best, but prepare for the worst. This week she has had more vaginal bleeding, and a followup ultrasound showed a fetus, alive, with a heartbeat, albeit a slow heartbeat. She was again counseled to hope for the best, but prepare for a possible miscarriage. I cannot imagine the limbo she must be in. I worry that I will run into her at the OB’s, as we both are going to the same OB office for care. I wonder what I will say, or what I should say, what I need to say.

How do other physicians cope with these difficult situations? I do not believe that a complete dissociation into professional identity is possible here. These issues hit the deepest emotional, irrational parts of us. For so many women, being pregnant or trying to get pregnant can represent a whole future; hope and loss, life and death, and is life-CHANGING, regardless of the outcomes.

What do people do?